insur. co won't pay for ADR & I'm running out of time

[Karee]

Karen - I am also a new Jr. Member - After reading your dilemma and others dealing with trying to get ins. co. to pay for ADR. I am a 65 yr. old female who had a spinal fusion in 1999 at L-4 L-5 level with all the hardware with harvest from the illiect crest - I have done ok untill a fall july 04 - Had a MRI in Nov. and now Dr. says I have to have another surgery to remove hardware and decompress L-3 L4 and re-install up to L-3 using cadaver bone this time - I am trying to find a surgeon who can do the ADR - but seems my only hope is Germany - I have had some contact with Stenum Hosp. and also Mark M******* who is a advocate for Dr. Zeegers and Bertagnoli- I also have Blue Cross and have had two converence calls with Blue Card worldwide & my home plan but they will not say if they will cover unless I have a procedure code. I checked with my ortho Dr. who is doing the charite ADR but due to FDA restrictions he can only do L-4 &L-5 level and age limit is 60 - The code they are trying to use is generic so no luck thier - I have contacted Malte Peterson @ Stenum trying to get one but have heard nothing- It is pointless for me to send films, reports etc. to Germany to see if I even am a candidate without knowing if my ins. will cover - Same thing with Mark M. fees to advocate for Zeegers & Dr.B- Any suggestions from anybody on how to get a procedure code??

[ESL]

I have a pre-approval cert from my insurance company that lists the following codes:

Diagnosis: 722.83
Procedure: 63090 63091 22851

[DWebster]

Karee, Mark is not an advocate for the doctors he is a patient advocate, he works for us. He just has a working relationship with Dr. Bertagnoli and Dr. Zeegers as well as many other doctors in the US. He has been a geat help to me but never told me where to go, only gave me options as to were I would be able to go and then help in the arrangements.

I just didn't want anyone to get the wrong idea about him. He really know his stuff and has many connection and not just for ADR.

[ans]

Casifer,

If you're in LA, why not see Drs. Regan or Bray. I had an authorization ok'd by Regan's office and I'm sure I'm not the first. Some speak well of Dr. Watkins. PM or email me if I can help.- ans

[casifer]

ans - thanks for the info. I actually do plan on making an appointment with Regan for at least a 2nd opinion, since he seems to be the most experienced in LA. I would definitely prefer Regan for the procedure too, but unfortunately he's not listed within my insurance co's (PHCS) network.
I too have heard very good things about Watkins.

[Karee]

D. Webster - I understand that Mark works for the paitents but what I meant was that he would be the one to set it up if you chose DR. Zeegers or Dr. B - I cant go any further with Mark untill I find out if my ins. Co. will cover - I have a real hard time understanding why all these ins. co. refuse to pay for ADR. My fusion in 1999 was 140K plus a year of pt., drugs etc. and now 6 yrs later I am faced with the same thing - When my ortho Dr. had a seminar on the ChariteADR( He is now dong this but only the FDA approved @ LR-4 & LR5 level with age 18-60 ( he told us all when you have a standard spine fusion it basically shifts the load to the segment above fusion, that is why so many have more than one - I cant tell you how many people I know who did not even fuse -I wonder if they keep any data on the fusion failures. I will try again Mon. with Ins. Co. and see what happens. Karee

[ans]

casifer,

I wish you well but pls. know that I'm very new to this game and just learning about the best docs here 'n there.

Good luck to you! ans

[Poncho]

Karen,

Perhaps going to Regan at Cedars would be your next option (that is if you not have already done that). The Charite is FDA approved - however,still getting resistance regarding insurance coverage.

I too was in the same position regarding insurance coverage (no ADRs FDA approved at that time)... I ended up going to Europe for surgery. But if you do this, make sure you will have a surgeon here who will do your follow up care. Going to Europe will most likely be out of pocket for you, but cheaper payinng out of pocket there than here in the States and they have more experienced surgeons there.

[Karen]

Yeah, I'd love to go to Dr. Regan but he's out of network for me (so is Delamarter).

I want to continue appealing, but I can't afford to keep up my COBRA premiums to Cigna if they aren't going to end up paying for the ADR at some point. Has anyone been denied, gone ahead with the surgery anyway (before the appeal process has fully run its course), and had their insurance company retroactively agree to pay? It seems to me that I'm on pretty thin ice here, and since I've been layed off, it isn't as though I have any leverage with my employer. I'm going to try to get some free advice from my UCLA mentor, a plaintiff's lawyer who happens to handle insurance bad faith, etc. If I find out anything useful, I'll post it.

Also, I've learned that I really need to be capable of working before the end of May or I'll be out of luck on applying for unemployment benefits. I'm just lying here biting what's left of my fingernails while I wait for a response from Bertagnoli or Zeegers. Am I dreaming to think that I might still get my ADR by late May? And am I right in thinking that either of them would charge about 21K, Euro?

Thanks.